Citation NR: 9708278
Decision Date: 03/10/97 Archive Date: 03/25/97
DOCKET NO. 94-30 000 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Winston-
Salem, North Carolina
THE ISSUE
Entitlement to service connection for an acquired psychiatric
disorder.
REPRESENTATION
Appellant represented by: The American Legion
WITNESS AT HEARING ON APPEAL
Veteran
ATTORNEY FOR THE BOARD
Suzie S. Gaston, Counsel
INTRODUCTION
The veteran had active military service from January 1981 to
October 1983. He has been represented throughout his appeal
by the Disabled American Veterans.
This matter came before the Board of Veterans’ Appeals
(hereinafter Board) on appeal from a rating decision of
February 1994, by the Winston-Salem, North Carolina Regional
Office (RO), which denied the veteran’s claim of entitlement
to service connection for recurrent major depression and a
personality disorder, not otherwise specified (NOS). The
notice of disagreement with this determination was received
in March 1994. The statement of the case was issued in June
1994. The substantive appeal was received in July 1994.
Following the receipt of Department of Veterans Affairs (VA)
medical records, a rating action of May 1995 confirmed the
previous denial of the veteran’s claim for service connection
for recurrent major depression and a personality disorder. A
supplemental statement of the case was issued in May 1995.
In May 1996, the Board remanded the case to the RO for
further development. A VA compensation examination was
conducted in July 1996. The veteran appeared and offered
testimony at a hearing before a hearing officer at the RO in
August 1996. A transcript of the hearing is of record. A
supplemental statement of the case was issued in August 1996.
CONTENTIONS OF APPELLANT ON APPEAL
The veteran essentially contends that he is entitled to
service connection for a psychiatric disorder which had its
onset during service. The veteran maintains that he had no
psychiatric problems prior to entering military service. He
alleges that his psychiatric problems began when he was
required to cut into dead bodies during transplant school
while on active duty and that he is currently unable to work
as a result of his military experiences.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991 & Supp. 1995), has reviewed and considered
all of the evidence and material of record in the veteran's
claims file. Based on its review of the relevant evidence in
this matter, and for the following reasons and bases, it is
the decision of the Board that the evidence is in equipoise
and therefore supports the veteran’s claim for entitlement to
service connection for anxiety disorder with depressive
symptoms.
FINDINGS OF FACT
1. All relevant evidence necessary for an equitable
disposition of the veteran’s claim has been obtained by the
RO.
2. During service, the veteran was seen and treated for
symptoms which included insomnia, anxiety, depression, crying
spells and agitation; his psychiatric disorder was variously
diagnosed as adjustment reaction with mixed personality
disorder, histrionic personality disorder, acute situational
reaction, anxiety disorder and adjustment disorder with
anxious mood related to stressful life events.
3. The veteran is currently diagnosed with anxiety disorder
with depressive symptoms which is based on symptoms similar
to those present during military service.
CONCLUSION OF LAW
Anxiety disorder with depressive symptoms was incurred in
active service. 38 U.S.C.A. §§ 1131, 5107 (West 1991);
38 C.F.R. § 3.303 (1996).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
The veteran's claim is "well-grounded" within the meaning of
38 U.S.C.A. § 5107(a) (West 1991). That is, the claim is
plausible. Moreover, all relevant facts have been properly
developed. Therefore, no further assistance to the veteran
is required to comply with the duty to assist as mandated by
38 U.S.C.A. § 5107(a).
A. Factual background.
The pertinent facts in this case are not in dispute and may
be briefly summarized. The record reflects that the veteran
entered active duty in January 1981. An enlistment
examination, conducted in August 1980, revealed no complaints
or findings referable to a psychiatric disorder. The service
medical records show that the veteran was seen in March 1981
with complaints of insomnia; he reported having similar
problems four years earlier while going through a divorce;
the assessment was probably situational reaction, unknown
etiology. In August 1981, it was reported that the veteran
had stress insomnia. In November 1982, the veteran was
referred to the psychiatric service at the Naval Hospital for
an evaluation; following a mental status evaluation, the
veteran was given a diagnosis of adjustment disorder with
anxious mood, related to stressful life events. When seen in
August 1983, it was noted that the veteran showed extreme
agitation and denial; he was subsequently admitted to
psychiatric service for evaluation, at which time he was
diagnosed with a dependent personality disorder, and an
administrative separation from service was recommended.
The service medical records further indicate that the veteran
was seen in September 1983 for dental pain; however, the
examiner reported that there was no evidence of any dental
disorder. The examiner stated that this was another
manifestation of the veteran’s manipulative histrionic
personality disorder. It was also noted that the veteran was
crying hysterically about his overall situation. When seen
several days later on September 23, 1983, the veteran was
crying and indicated that he had felt depressed and down for
the past three days. The veteran was next seen on October 5,
1983, at which time it was indicated that he had tension
headaches and had received a psychiatric discharge that day.
On October 12, 1983, the veteran was seen for increasing
headaches, secondary to stress; the assessment was anxiety.
Received in November 1993 were private treatment records
covering the period from November 1983 to May 1991. These
records show primary symptoms of depression, anxiety, stress,
tension, and references to suicidal ideations. Treatment
records dated November 1983, January 1984 and May 1986
reflect a diagnosis of adjustment disorder with mixed
emotional features. These records indicate that, in January
1989, the veteran was brought in by his father for complaints
of drug abuse; it was also noted that, on admission, the
veteran was angry and irritable with some depression. The
discharge diagnoses were adjustment disorder with mixed
disturbance of emotions and narcotic abuse. The records
further indicate that the veteran was subsequently admitted
to the hospital in May 1991. He indicated at that time that
he felt as though his life was crumbling about him because he
had no current living situation; on admission, he described
suicidal thoughts, but he had no plans. The discharge
diagnoses were dysthymic disorder, polysubstance abuse and a
borderline personality disorder.
Received in November 1993 was a VA hospital summary which
showed that the veteran was admitted to a hospital in
September 1993, requesting help with his prescription drug
abuse. It was noted that the veteran had been treated for
major depression and a borderline personality disorder for
may years, with trials on numerous antidepressants due to
depression and suicidal gestures. The veteran was admitted
to the substance abuse treatment rehabilitation program. The
discharge diagnoses were polysubstance dependency, severe;
major depression, in remission; and borderline personality
disorder. Also received in November 1993 were additional VA
medical records, covering the period from January 1993 to
September 1993, which show that the veteran continued to
receive clinical attention for depression.
The veteran was afforded a VA compensation examination in
November 1993, at which time he reported continued
psychiatric problems since leaving service in 1983. It was
noted that the veteran had been admitted several times for
depression and suicidal ideation; it was further noted that
he had also had several admissions primarily for his
difficulty with prescription drugs. The veteran also
reported that, since service, his longest period of
employment was from March 1985 to January 1987, working in an
electronics supply store. On mental status evaluation, the
veteran was reported to be neatly dressed in casual clothing.
He appeared alert and pleasant. The examiner reported that
verbal productivity, orientation, memory, insight and
judgment appeared adequate. The diagnoses were major
depression, recurrent, and a personality disorder NOS.
Received in December 1993 were private treatment records,
dated from October 1991 to July 1993, indicating that the
veteran continued to receive clinical attention and treatment
for depressive and personality disorders. These records also
indicate that the veteran received treatment for a substance
abuse disorder. Among these records is a hospital report,
dated in July 1993, which showed that the veteran was
admitted on petition for commitment because of alleged self
destructive behavior and threatening to harm himself and
others. Following an evaluation, the pertinent diagnosis
reported was a personality disorder, NOS.
Received in July 1994 were VA medical records, dated from
March 1992 to May 1994, indicating that the veteran continued
to be seen at the mental health clinic where he received
counseling and treatment for complaints of depression,
agitation, substance abuse, and other problems related to
marital conflict. The veteran was admitted to a hospital in
February 1993, complaining of increased feelings of
depression; he also reported symptoms of insomnia, and loss
of appetite without significant weight changes. During the
hospitalization, the veteran was treated with medication and
therapy; the discharge diagnoses included dysthymia,
polysubstance dependence, and rule out a personality
disorder.
The veteran was afforded a psychiatric examination by the VA
in July 1996, at which time he indicated that his psychiatric
problems began in service. The veteran reported that, after
completing corpsman school, he was sent to transplant school
which involved disturbing procedures. The veteran explained
that, after failing to obtain a transfer from that school, he
deliberately failed and continued to have psychiatric
problems for which he was hospitalized on two separate
occasions. The veteran said that he continued to have
difficulties after his separation from service, and he had
been unable to hold a job for any length of time. The
veteran also indicated that he was currently in treatment at
a chemical dependency center due to a long history of
problems with prescription drug abuse. The veteran further
indicated that a number of different diagnoses had been made
which included major depression with intrusive thoughts of
his experiences in transplant school. On interview, the
veteran was reported to be neatly dressed in casual clothes.
He appeared alert, tense and restless and paced around the
room during the examination. He answered questions readily.
Verbal productivity, orientation, memory, insight and
judgment appeared adequate. Following the psychological
evaluation, the psychiatrist reported the diagnoses of
anxiety disorder, NOS with depressive symptoms, and
personality disorder NOS. The examiner stated that, in his
opinion, veteran’s current symptoms support a continuation of
symptoms noted in service.
The veteran was also afforded a psychological evaluation in
July 1996. The examiner noted that the veteran had had at
least six inpatient hospitalizations for depression and
suicidal ideation. He also noted that the veteran had had
numerous treatments for abuse of prescribed drugs. The
examiner concluded that current evaluation presented
equivocal results. The examiner reported that the MMPI-2 was
of questionable validity due to probable exaggeration of
symptoms. The examiner also reported that the veteran’s
responses on the TSI suggested the presence of fairly
substantial depressive and anxiety symptoms; and, the results
of the Rorschach were suggestive of a substantial coping
deficit and mild depressive symptoms. The examiner further
reported that there was evidence throughout the test of
substantial pathological personality traits involving passive
dependent, passive-aggressive, schizoid, and obsessive
compulsive features. The examiner stated that, overall,
there was evidence of a mixed anxiety disorder with affective
features, as well as a personality disorder NOS.
At the time of his personal hearing in August 1996, the
veteran indicated that he had been unemployed since 1991; he
stated that he had been awarded Social Security
Administration disability benefits based on his psychiatric
disorders. The veteran reported that, following corpsman
school where he did very well, he was sent to transplant
school. The veteran explained that, as part of the
transplant team, they had to cut up cadavers and remove bones
for research; he indicated that he considered that procedure
to be butchery. He said that, when they refused to transfer
him from that program, he purposely flunked out; he
thereafter began to abuse various drugs. The veteran related
that he was subsequently given an administrative discharge,
and began receiving treatment for his psychiatric disorder
within one month after discharge. He added that he continued
to have bad dreams as a result of that experience.
B. Legal analysis.
Service connection may be granted for a chronic disability
resulting from disease or injury incurred in or aggravated by
active service. 38 U.S.C.A. § 1131. Service connection may
also be granted for any disease diagnosed after discharge,
when all the evidence, including that pertinent to service,
establishes that the disease was incurred in service. 38
C.F.R. § 3.303(d).
Congenital or developmental defects are not diseases or
injuries within the meaning of legislation applicable to
service connection. 38 C.F.R. § 3.303(c). "[Personality]
disorders are developmental in nature, and, therefore, not
entitled to service connection. Regulatory authority
provides that personality disorders will not be considered as
disabilities under terms of the [Schedule for Rating
Disabilities]. See 38 C.F.R. §§ 4.9, 4.127 (1991).
Therefore, as a matter of law there is no compensable rating
disability." Beno v. Principi, 3 Vet.App. 489, 441 (1992).
However, if there is a chronic disease shown as such in
service so as to permit a finding of service connection,
subsequent manifestations of the same chronic disease at any
later date, however remote, are service connected, unless
clearly attributable to intercurrent causes. For the showing
of chronic disease in service there is required a combination
of manifestations sufficient to identify the disease entity,
and sufficient observation to establish chronicity at the
time, as distinguished from merely isolated findings or a
diagnosis including the word "chronic." Continuity of
symptomatology is required where the condition noted during
service is not, in fact, shown to be chronic or where the
diagnosis of chronicity may be legitimately questioned. When
the fact of chronicity in service is not adequately
supported, then a showing of continuity after discharge is
required to support the claim. 38 C.F.R. § 3.303(b).
In this case, the Board notes that the service medical
records clearly indicate that the veteran received continuous
treatment in service for symptoms which included depression,
anxiety, agitation, crying spells and insomnia. The Board
further notes that the veteran’s symptoms were given various
diagnoses, including adjustment reaction with mixed emotional
features, acute situational reaction, anxiety, personality
disorder, adjustment disorder with anxious mood, and
dependent personality disorder. The post-service medical
records reflect that the veteran continued to receive
clinical attention for similar symptoms, predominantly
depression, beginning in November 1983. The records
reflected a diagnosis of adjustment disorder with mixed
emotional features and personality disorder until May 1991,
at which time the veteran was given a diagnosis of dysthymic
disorder. However, when the veteran was most recently
examined in July 1996, the psychologist reported that there
was fairly substantial evidence of anxiety and depression
which may be related to a specific traumatic precipitating
event; he stated that there was evidence of a mixed anxiety
disorder as well as a personality disorder. The Board also
finds it significant that the psychiatrist stated that
veteran’s current symptoms supported a continuation of
symptoms noted in service.
The Board concludes that, the above opinions, in conjunction
with the other evidence, result in a record in relative
equipoise as to the origin of the veteran’s anxiety disorder
with depressive symptoms. It is noteworthy that the
prominent symptom for which the veteran was treated in
service was depression; and, an assessment of anxiety was
made in October 1983. Under these circumstances, the Board
is of the opinion that, according to the veteran the benefit
of the doubt, his currently diagnosed anxiety disorder with
depressive features, notwithstanding its initial diagnosis
several years after service, is related to his period of
active military service. Accordingly, a grant of service
connection for anxiety disorder with depressive features is
warranted. 38 U.S.C.A. §§ 1131, 5107; 38 C.F.R. § 3.303;
Gilbert v. Derwinski, 1 Vet.App. 49 (1990).
ORDER
Service connection for anxiety disorder with depressive
symptoms is granted.
R. F. WILLIAMS
Acting Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991 & Supp. 1996), a decision of the Board of Veterans'
Appeals granting less than the complete benefit, or benefits,
sought on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans' Judicial Review Act,
Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The
date which appears on the face of this decision constitutes
the date of mailing and the copy of this decision which you
have received is your notice of the action taken on your
appeal by the Board of Veterans' Appeals.
- 2 -